Tag Archives: medical

Court blocks law that’d close Mississippi’s only abortion clinic

A federal court earlier this month permanently blocked Mississippi’s law that threatened to close the state’s only abortion clinic by setting a hospital-privileges requirement the clinic couldn’t fulfill.

The ruling comes eight months after the U.S. Supreme Court blocked a similar law in Texas.

In a statement, Center for Reproductive Rights President and CEO Nancy Northup called the ruling the latest victory for women’s health and rights.

“Our landmark win at the Supreme Court last summer continues to reverberate across the nation,” Northup said. “Any politician trying to roll back women’s constitutional rights should take notice and remember the law is on our side.”

An emailed request for comment from Republican Gov. Phil Bryant’s office was not immediately returned.

Bryant has said the law he signed in 2012 was designed to help women.

Mississippi was one of several states with laws saying physicians who work at an abortion clinic must obtain privileges to admit patients to a local hospital. Mississippi’s law never fully took effect because of a protracted court battle.

Jackson Women’s Health Organization sued the state before the law was to take effect in July 2012, saying the requirement could block access to a constitutionally protected medical procedure.

U.S. District Judge Daniel P. Jordan III let the law take effect but prevented the state from closing the clinic while physicians sought hospital privileges.

The state sought to overturn Jordan’s decision and the 5th U.S. Circuit Court of Appeals ruled in 2014 that the law could cut off abortion access in Mississippi.

On Medicaid money, GOP has win-or-lose proposition for states

New England’s bucolic countryside looks much the same on either side of the Connecticut River separating Vermont from New Hampshire. But Medicaid beneficiaries are far better off in Vermont.

Vermont generously funds its Medicaid program. It provides better benefits, such as dental care, and pays doctors more than New Hampshire’s program does. That brings more doctors into the program, giving enrollees more access to care.

New Hampshire has twice Vermont’s population, but Vermont spends almost as much on Medicaid and covers more enrollees. Under the complicated formulas that set federal funding, Vermont’s substantial investment helps it capture nearly as much aid from the government as New Hampshire gets.

States’ policies differ about who or what to cover in Medicaid, and those decisions have led to historical variances in how much federal money they receive. House Republicans’ effort to shrink federal Medicaid spending would lock in the differences in a way that favors those already spending high amounts per enrollee.

“Republicans are finding out why changing Medicaid is so hard and why the easiest thing to do is to do nothing given the substantial variation in federal spending across states,” said John Holahan, a health policy expert with the nonpartisan Urban Institute.

Here’s why.

Medicaid, the national health program for low-income people that covers about 1 in 5 Americans, is 60 percent funded by the federal government and 40 percent by states. Total spending in 2015 was about $532 billion, according to the latest official data.

Federal funding is open-ended, which means the government guarantees states it will pay a fixed rate of their Medicaid expenses as spending rises.

Those matching rates are tied to average personal incomes and favor the lowest-income states. Mississippi has the highest Federal Matching Assistance Percentage — 76 — while 14 wealthy states, including New York and California, get the minimum 50 percent from the federal government.

But state Medicaid spending varies significantly, too, and that influences how much federal money each receives to fund its program. State policies about how generous benefits should be and how much to pay doctors and hospitals account for those differences.

GOP leaders want to give states a set amount of money each year based on the number of Medicaid enrollees they had in 2016, a formula known as per-capita caps.

A per-capita system would benefit high-spending states already receiving relatively rich allotments from the government, the Urban Institute said in a paper last September.

According to its estimates, if the system were in effect this year, Vermont would receive $6,067 per enrollee — one of the highest allotments in the country — while New Hampshire would get the least, just $3,084 per enrollee.

Per-capita caps would limit the government’s Medicaid spending because it would no longer be on the hook to help cover states’ rising costs. But caps also would shift costs and financial risks to the states and could force them to cut benefits or eligibility to manage their budgets.

“It would present a huge problem,” said Adam Fox, a spokesman for the Colorado Consumer Health Initiative, an advocacy group.

Under the GOP bill, federal Medicaid funding to states would be adjusted annually based on a state’s enrollment and medical inflation. But that would not be enough to keep up with rising Medicaid spending per enrollee, which would force states to put up more of their money or scale back the program, the nonpartisan Congressional Budget Office said March 13.

Other analyses of the GOP plan have reached the same conclusion.

Since 1999, however, the average annual growth rate in Medicaid spending per enrollee has risen more slowly than medical inflation, according to MACPAC, the Medicaid and CHIP Payment and Access Commission, which advises Congress.

Republicans argue that overhauling federal Medicaid spending as they propose would hold down federal costs while giving states more leeway to run their programs as they see fit. “This incentive would help encourage efficiencies and accountability with taxpayer funds,” House Speaker Paul Ryan wrote last June in his white paper, A Better Way.”

Rep. Greg Walden (R-Ore.), chairman of the powerful House Energy and Commerce Committee, which has oversight of health care matters, sounded a similar note at a press conference in Washington, D.C., when the GOP plan was announced. “I think it’s really important to empower states and to put Medicaid on a budget,” he said.

But Fox argued the opposite would happen under a per-capita system — instead of gaining more control over their Medicaid programs, states would not be able to meet their needs because they’d have fewer dollars to decide how to spend, he said.

Bill Hammond, director of health policy for the nonpartisan Empire Center for Public Policy in New York, said House leaders’ decision to tie future Medicaid funding to medical inflation could help mute concerns that funding wouldn’t keep up with rising costs, but would not address the fairness issue of giving some states higher per-capita amounts than others.

“If a low-spending state decides it wants to spend more money on paying hospitals and doctors or adding more benefits, they would have a harder time doing that without breaking the federal cap,” he said.

Medicaid advocates in New Hampshire are worried because their state has few alternatives to make up for a loss in federal funding. New Hampshire lacks an income or sales tax.

“There is a tremendous amount of fear among families here as Republicans try to dismantle the ACA,” said Martha-Jean Madison, co-director of New Hampshire Family Voices.

Published under a Creative Commons license. Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.

Colorado House moves to set new limit on homegrown pot

Colorado is moving to curb the nation’s most generous marijuana allowance for medical patients growing their own pot plants. The state House gave preliminary approval to a bill limiting marijuana patients 16 plants in their homes, down from 99.

The measure aims to make it harder to grow pot outside the taxed and regulated commercial pot system.

Colorado regulators have tried for years to stop people from growing large amounts of pot without state taxation or oversight. But because Colorado’s constitution gives people the right to grow as much pot as their doctors recommend, the state has had a hard time making that happen.

“We need to close this loophole,” said Rep. KC Becker, a Boulder Democrat and sponsor of the bill.

This year’s effort would say that marijuana patients can’t have more than 16 plants in a residential property. The change would force those patients to either move to an industrial or agricultural area, or shop at a dispensary.

Of the 28 states with legal medical marijuana, none but Colorado currently allows more than 16 pot plants per home.

Many Colorado jurisdictions including Denver already have per-home plant limits, usually at 12. But the lack of a statewide limit makes it difficult for police to distinguish between legitimate patients and fronts for black-market weed, bill supporters argued Friday.

“The time has come for us … to give law enforcement the guidance they need,” said Rep. Cole Wist, a Centennial Republican and another bill sponsor.

Marijuana patients have been flooding lawmakers with complaints about the bill, which was introduced just last week. The first hearing on the measure lasted until near midnight.

Lawmakers softened the bill by raising its original limit from 12 plants to 16 plants, and by saying that patients caught with too much pot in the House would face a petty offense, and felony charges only later.

But those changes weren’t enough for some Democrats, who argued in vain that it shouldn’t be a felony until the third offense to have too much pot in the home. They argued that the limits won’t hurt criminal drug operations, which could simply grow their plants in areas that aren’t zoned residential.

“A lot of patients are on fixed incomes. They’re ill,” said Rep. Adrienne Benavidez, D-Commerce City. “Cartels have the money to go rent warehouses.”

The resistance effort even brought one lawmaker to tears. Rep. Steve Lebsock, D-Thornton, held a stack of patient letters and said the change would hurt people who can’t afford to shop in dispensaries.

“We’re throwing patients in jail!” Lebsock cried.

But Republicans sided with other Democrats to prevail on an unrecorded voice vote. The bill faces one more formal vote next week before heading to the Senate, where its prospects are strong.

A companion bill — to give law enforcement more money to sniff out illegal pot growers — is awaiting a House vote Monday.

Gov. John Hickenlooper backs the plant crackdown and has called on lawmakers to send him a statewide limit.

Sanders announces health care rallies from coast to coast

U.S. Sen. Bernie Sanders says more than 100 rallies will take place from coast to coast on Feb. 25 to fight Republican attempts to take health care away from 20 million Americans.

Sanders, in a statement, said, “The American people will let Republicans know they are standing against their attempts to repeal the Affordable Care Act, throwing 20 million Americans off of their health insurance, privatizing Medicare, making massive cuts in Medicaid, raising the cost of prescription drugs for seniors and, at the same time, giving a massive tax break to the top 1 percent. The American people want to improve the Affordable Care Act, not destroy it.”

Sanders, the Senate Democrats’ outreach leader, and Senate Democratic Leader Chuck Schumer previously sent a letter calling for rallies to oppose efforts by President Donald Trump and Republicans in Congress to repeal the Affordable Care Act.

Said Schumer and Sanders in the letter, “The Republican Party’s plan to repeal the Affordable Care Act is in chaos. Public support for the law is at an all-time high, while the number of Americans supporting its immediate repeal without a replacement has dipped below 15 percent. It is critical we seize this momentum.”

For details on where rallies will take place, click here.

On Capitol Hill: Cannabis Caucus organizes in Congress

Alaska Republican Rep. Don Young says he never smoked marijuana, but he’s a member of the newest caucus on Capitol Hill — the Cannabis Caucus.

Four House members announced the formation of the caucus last week.

While the name may elicit smiles, the lawmakers said their intentions are serious: Keep federal policies from interfering with states as they enact laws that allow for recreational or medical marijuana.

“I believe in states’ rights. Alaska voted to legalize it, pretty large margin,” said Young, 83. “The federal government should stay out of it, period.”

Eight states and the District of Columbia have legalized small amounts of marijuana for adult recreational use.

Another 28 states have legalized medical marijuana. The members of the newest caucus said they expect strong interest in joining their group based on the state trends.

“Once a state has acted, members of Congress are interested in defending and working with their constituencies,” said Rep. Jared Polis, D-Colo.

The leaders of the group include two Republicans, Rep. Dana Rohrabacher of California and Young. The Democratic co-chairmen are Rep. Earl Blumenauer of Oregon and Polis.

For the record, the lawmakers, for the most part, said they don’t use marijuana.

Young said he’s never used it and doesn’t really believe in it.

Polis said he’s never used it either.

Blumenauer said he is going to wait until marijuana is legal federally before using it.

Rohrabacher said he recently had surgery on his arm and placed a candle infused with cannabis on it because of the pain. “I got sleep for the first time in weeks after that,” he said.

Among the group’s goals: Keep the federal government from blocking research into marijuana for medical purposes and make it easier for marijuana businesses to operate.

The businesses generally can’t accept credit or debit cards due to card companies’ fears about liability for money laundering or other offenses. Nor can they fully deduct their business expenses, Blumenauer said.

Warren wants to pull pot shops out of banking limbo

As pot shops sprout in states that have legalized the drug, they face a critical stumbling block — lack of access to the kind of routine banking services other businesses take for granted.

U.S. Sen. Elizabeth Warren, a Massachusetts Democrat, is leading an effort to make sure vendors working with legal marijuana businesses, from chemists who test marijuana for harmful substances to firms that provide security, don’t have their banking services taken away.

It’s part of a wider effort by Warren and others to bring the burgeoning $7 billion marijuana industry in from a fiscal limbo she said forces many shops to rely solely on cash, making them tempting targets for criminals.

After voters in Warren’s home state approved a November ballot question to legalize the recreational use of pot, she joined nine other senators in sending a letter to a key federal regulator, the Financial Crimes Enforcement Network, calling on it to issue additional guidance to help banks provide services to marijuana shop vendors.

Twenty-eight states have legalized marijuana for medicinal or recreational use.

Warren, a member of the Senate Banking Committee, said there are benefits to letting marijuana-based businesses move away from a cash-only model.

“You make sure that people are really paying their taxes. You know that the money is not being diverted to some kind of criminal enterprise,” Warren said recently. “And it’s just a plain old safety issue. You don’t want people walking in with guns and masks and saying, ‘Give me all your cash.””

A spokesman for the Financial Crimes Enforcement Network said the agency is reviewing the letter.

There has been some movement to accommodate the banking needs of marijuana businesses.

Two years ago, the U.S. Department of the Treasury gave banks permission to do business with legal marijuana entities under some conditions. Since then, the number of banks and credit unions willing to handle pot money rose from 51 in 2014 to 301 in 2016.

Warren, however, said fewer than 3 percent of the nation’s 11,954 federally regulated banks and credit unions are serving the cannabis industry.

Taylor West, deputy director of the National Cannabis Industry Association, a trade organization for 1,100 marijuana businesses nationwide, said access to banking remains a top concern.

“What the industry needs is a sustainable solution that services the entire industry instead of tinkering around the edges,” Taylor said. “You don’t have to be fully in favor of legalized marijuana to know that it helps no one to force these businesses outside the banking system.”

Sam Kamin, a professor at the University of Denver Sturm College of Law who studies marijuana regulation, said there’s only so much states can do on their own.

“The stumbling block over and over again is the federal illegality,” he said.

The federal government lumps marijuana into the same class of drugs as heroin, LSD and peyote. Democratic President Barack Obama’s administration has essentially turned a blind eye to state laws legalizing the drug, and supporters of legalizing marijuana hope Republican President-elect Donald Trump will follow suit.

Trump officials did not respond to a request for comment. During the presidential campaign, Trump said states should be allowed to legalize marijuana and has expressed support for medicinal use. But he also has sounded more skeptical about recreational use, and his pick for attorney general, Alabama U.S. Sen. Jeff Sessions, is a stern critic.

Some people in the marijuana industry say the banking challenges are merely growing pains for an industry evolving from mom-and-pop outlets.

Nicholas Vita, CEO of Columbia Care, one of the nation’s largest providers of medical marijuana products, said it’s up to marijuana businesses to make sure their financial house is in order.

“It’s not just as simple as asking the banks to open their doors,” Vita said. “The industry also needs to develop a set of standards that are acceptable to the banks.”

Minnesota is leading the rest of country in banning germ-killer triclosan

Minnesota’s first-in-the nation ban on soaps containing the once ubiquitous germ-killer triclosan takes effect Jan. 1, but the people who spearheaded the law say it’s already having its desired effect on a national level.

The federal government caught up to Minnesota’s 2014 decision with its own ban that takes effect in September 2017. Major manufacturers have largely phased out the chemical already, with some products being marketed as triclosan-free.

And it’s an example of how changes can start at a local level.

“I wanted it to change the national situation with triclosan and it certainly has contributed to that,” said state Sen. John Marty, an author of Minnesota’s ban.

Triclosan once was widely used in anti-bacterial soaps, deodorants and even toothpaste. But studies began to show it could disrupt sex and thyroid hormones and other bodily functions, and scientists were concerned routine use could contribute to the development of resistant bacteria. And University of Minnesota research found that triclosan can break down into potentially harmful dioxins in lakes and rivers.

The group Friends of the Mississippi River and its allies in the Legislature, including Marty, got Gov. Mark Dayton to sign a ban in 2014 that gave the industry until Jan. 1, 2017, to comply.

In September, the FDA banned triclosan along with 18 other anti-bacterial chemicals from soaps nationwide, saying manufacturers had failed to show they were safe or more effective at killing germs than plain soap and water. However, the FDA allowed the use of some triclosan products such as Colgate Total toothpaste, saying it’s effective at preventing gingivitis.

Marty and Trevor Russell, the water program director for Friends of the Mississippi River, acknowledged they can’t take direct credit for the FDA’s action because that rulemaking process began in 1978, though it didn’t finalize the rule until after a legal battle with the Natural Resources Defense Council.

However, the Minnesota men hope their efforts helped turn opinions against the chemical and are confident the state’s ban helped prod manufacturers to accelerate a phase-out that some companies such as Procter & Gamble and Johnson & Johnson had already begun.

Most major brands are now reformulated, said Brian Sansoni, spokesman for the American Cleaning Institute, a lobbying group. Soaps containing triclosan on store shelves are likely stocks that retailers are just using up, he said.

Russell noted he recently found Dial liquid anti-bacterial hand soap at two local Wal-Marts, two supermarkets and a Walgreens.

The industry is now submitting data to the FDA on the safety and effectiveness of the three main replacements, benzalkonium chloride, benzethonium chloride and chloroxylenol.

“Consumers can continue to use these products with confidence, like they always have,” Sansoni said.

By going first, Russell said, Minnesota can identify any issues with implementing the ban and share it with the rest of the country.

The Minnesota Department of Health will remind consumers and businesses of the ban’s start.

Trump action on health care could cost Planned Parenthood

One of President-elect Donald Trump’s first, and defining, acts next year could come on Republican legislation to cut off taxpayer money from Planned Parenthood.

Trump sent mixed signals during the campaign about the 100-year-old organization, which provides birth control, abortions and various women’s health services. Trump said “millions of women are helped by Planned Parenthood,” but he also endorsed efforts to defund it. Trump once described himself as “very pro-choice.” Now he’s in the anti-abortion camp.

The Republican also has been steadfast in calling for repeal of President Barack Obama’s health care law and the GOP-led Congress is eager to comply.

One of the first pieces of legislation will be a repeal measure that’s paired with cutting off money for Planned Parenthood.

While the GOP may delay the impact of scuttling the law for almost four years, denying Planned Parenthood roughly $400 million in Medicaid funds would take effect immediately.

“We’ve already shown what we believe with respect to funding of Planned Parenthood,” House Speaker Paul Ryan, R-Wis., told reporters last month. “Our position has not changed.”

Legislation to both repeal the law and cut Planned Parenthood funds for services to low-income women moved through Congress along party lines last year. Obama vetoed it; Trump’s win removes any obstacle.

Cutting off Planned Parenthood from taxpayer money is a long-sought dream of social conservatives, but it’s a loser in the minds of some GOP strategists.

Planned Parenthood is loathed by anti-abortion activists who are the backbone of the GOP coalition. Polls, however, show that the group is favorably viewed by a sizable majority of Americans — 59 percent in a Gallup survey last year, including more than one-third of Republicans.

“Defunding Planned Parenthood as one of their first acts in the New Year would be devastating for millions of families and a huge mistake by Republicans,” said incoming Senate Minority Leader Charles Schumer, D-N.Y.

Democrats pledge to defend the group and they point to the issue of birth control and women’s health as helping them win Senate races in New Hampshire and Nevada this year. They argue that Trump would be leading off with a political loser.

But if he were to have second thoughts and if the Planned Parenthood provision were to be dropped from the health law repeal, then social conservatives probably would erupt.

“They may well be able to succeed, but the women of America are going to know what that means,” said Rep. Diana DeGette, D-Colo., citing reduced access to services Planned Parenthood clinics provide. “And we’re going to call Republicans on the carpet for that.”

At least one Republican senator, Susan Collins of Maine, may oppose the effort.

Collins has defended Planned Parenthood, saying it “provides important family planning, cancer screening, and basic preventive health care services to millions of women across the country.” She voted against the health overhaul repeal last year as a result.

Continued opposition from Collins, which appears likely, would put the repeal measure on a knife’s edge in the Senate, where Republicans will have a 52-48 majority next year.

Senate GOP leaders could afford to lose just one other Republican.

Anti-abortion conservatives have long tried to cut Planned Parenthood funds, arguing that reimbursements for nonabortion services such as gynecological exams help subsidize abortions. Though Planned Parenthood says it performed 324,000 abortions in 2014, the most recent year tallied, the vast majority of women seek out contraception, testing and treatment of sexually transmitted diseases, and other services including cancer screenings.

The defunding measure would take away roughly $400 million in Medicaid money from the group in the year after enactment, according to the nonpartisan Congressional Budget Office, and would result in roughly 400,000 women losing access to care.

One factor is that being enrolled in Medicaid doesn’t guarantee access to a doctor, so women denied Medicaid services from Planned Parenthood may not be able to find replacement care.

Planned Parenthood says private contributions are way up since the election, but that they are not a permanent replacement for federal reimbursements. “We’re going to fight like hell to make sure our doors stay open,” said Planned Parenthood spokeswoman Erica Sackin.

Doctors, hospitals say ‘show me the money’ before treating patients

Tai Boxley needs a hysterectomy. The 34-year-old single mother has uterine prolapse, a condition that occurs when the muscles and ligaments supporting the uterus weaken, causing severe pain, bleeding and urine leakage.

Boxley and her 13-year-old son have health insurance through her job as an administrative assistant in Tulsa, Oklahoma. But the plan has a deductible of $5,000 apiece, and Boxley’s doctor said he won’t do the surgery until she prepays her share of the cost. His office estimates that will be as much as $2,500. Boxley is worried that the hospital may demand its cut as well before the surgery can be performed.

“I’m so angry,” Boxley said. “If I need medical care I should be able to get it without having to afford it up front.”

At many doctors’ offices and hospitals, a routine part of doing business these days is estimating patients’ out-of-pocket payments and trying to collect it up front.

Eyeing retailers’ practice of keeping credit card information on file, “there’s certainly been a movement by health care providers to store some of this information and be able to access it with patients’ permission,” said Mark Rukavina, a principal at Community Health Advisors in Chestnut Hill, Massachusetts, who works with hospitals on addressing financial barriers to care.

But there’s a big difference between handing over a credit card to cover a $20 copayment versus suddenly being confronted with a $2,000 charge to cover a deductible, an amount that might take months to pay off or exceed a patient’s credit limit. Doctors may refuse to dispense needed care before the payment is made, even as patient health hangs in the balance.

The strategy leaves patients financially vulnerable. Once a charge is on a patient’s credit card, they may have trouble contesting a medical bill. Likewise, a service placed on a credit card represents a consumer’s commitment that the charge was justified, so nonpayment is more likely to harm a credit score.

Approximately three-quarters of health care and hospital systems ask for payment at the time services are provided, a practice known as “point-of-service collections,” estimated Richard Gundling, a senior vice president at the Healthcare Financial Management Association, an industry group. He could not say how many were doing so for higher priced services or for patients with high-deductible plans, situations that would likely result in out-of-pocket outlays of hundreds or thousands of dollars.

“For providers, there’s more risk with these higher deductibles, because the chance of being able to collect it later diminishes,” Gundling said.

But the practice leaves many patients resentful.

After arriving by ambulance at the emergency department, Susan Bradshaw lay on a gurney in her hospital gown with a surgical bonnet on her head, waiting to be wheeled into surgery to remove her appendix at a hospital near her home in Maitland, Fla. A woman in street clothes approached her. Identifying herself as the surgeon’s office manager she demanded that Bradshaw make her $1,400 insurance payment before the surgery could proceed.

“I said, ‘You have got to be kidding. I don’t even have a comb,’” Bradshaw, a 68-year-old exhibit designer, told the woman on that night eight years ago. “I don’t have a credit card on me.”

The woman crossed her arms and Bradshaw remembers her saying, “You have to figure it out.”

As providers aim to maximize their collections, many contract with companies that help doctors and hospitals secure payments up front, often providing scripts that prompt staff to talk with patients about their payment obligations and discuss payment scenarios as well as software that can estimate what a patient will owe.

But as hospitals and doctors push for point-of-service payments to reduce bad debt from patients with increasingly high deductibles, the risk is that patients will delay care and end up in the emergency room, Rukavina said. “Patients are essentially paying for their procedures up front,” he said. “It may not be a significant amount compared to their salary, but they don’t necessarily have it available at the time of service.”

The higher their deductible, the less likely patients are to pay what they owe, according to an analysis of 400,000 claims by the Advisory Board, a health care research and consulting firm. While more than two-thirds of patients with a deductible of less than $1,000 were likely to pay at least some portion of what they owe, just 36 percent of those with deductibles of more than $5,000 did so, the analysis found.

Fifty-one percent of workers with insurance through their employer had a deductible of at least $1,000 for single coverage this year, according to the Kaiser Family Foundation’s annual survey of employer health insurance. (KHN is an editorially independent program of the foundation.)

Boxley pays $110 a month for her family plan. She could not afford the premiums on plans with lower deductibles that her employer offered. She plans to talk with the doctor and hospital about setting up a payment plan so she can get the surgery in January.

“I’ll make payments,” Boxley said, although she acknowledged what she could pay monthly would be small. If that doesn’t pan out, she figures she’ll have to use student loan money she got for graduate school to cover what she owes.

Still, experts say that trying to pin patients down for payment in more acute settings, such as the emergency department, may cross a line.

Under the federal Emergency Medical Treatment and Labor Act (EMTALA), a patient who has a health emergency has to be stabilized and treated before any hospital personnel can discuss payment with them. If it’s not an emergency, however, those discussions can occur before treatment, said Dr. Vidor Friedman, an emergency physician who is the secretary-treasurer of American College of Emergency Physicians’ board of directors.

Bradshaw finally got her appendix removed by calling a friend, who read his MasterCard number over the phone. The surgery was uneventful and Bradshaw was home within 24 hours.

“It’s a very murky, unclear situation,” Friedman said of Bradshaw’s experience, noting that a case might be made that her condition wasn’t life threatening. “At the very least it’s poor form, and goes against the intent if not the actual wording of EMTALA.”

Please visit khn.org/columnists to send comments or ideas for future topics for the Insuring Your Health column.

Published courtesy of Kaiser Health News.

For Trump and GOP, ‘Obamacare’ repeal is complex and risky

Here’s the idea: Swiftly pass a repeal of President Barack Obama’s health care law, perhaps soon enough for Donald Trump to sign it the day he takes the presidential oath.

Then approve legislation restructuring the nation’s huge and convoluted health care system — despite Republican divisions, Democratic opposition and millions of jittery constituents.

What could go wrong?

With Republicans controlling the White House and Congress in January, they’re faced with delivering on their long-time promise to repeal and replace “Obamacare.”

Here are hurdles they’ll face:

SPEED VS DELIBERATION

Trump and congressional Republicans will be under intense pressure from their core conservative supporters to repeal Obama’s 2010 health care law — and fast. After all, Congress already sent Obama a repeal bill last January, which he vetoed, and many GOP voters will see no reason for delays this time.

But there probably won’t be anything fast about Congress’ effort to replace Obama’s law, which is likely to take many months.

While the replacement effort is underway, Republicans will risk aggravating up to 30 million people who are covered by the law or buy policies with prices affected by its insurance marketplace. Democrats will be sure to accuse the GOP of threatening the health care of millions.

A SOLUTION

Nothing’s been decided, but here’s one likely scenario:

The new Congress, which convenes Jan. 3, tries to quickly approve legislation repealing Obama’s health care law, maybe completing it by Trump’s Jan. 20 inauguration or soon after. But the repeal would not take effect until the future, perhaps a year later, to give lawmakers time to fashion a replacement. The version Obama vetoed had a two-year delay.

Seemingly acknowledging that two-step process, Vice President-elect Mike Pence said Sunday on “Fox News Sunday” that Trump “wants to focus out of the gate on repealing Obamacare and beginning the process of replacing Obamacare.”

Because Republicans will control the Senate by just 52-48, Congress will first have to approve special budget procedures to prevent Democrats from stopping repeal legislation by filibuster. Bill-killing filibusters require 60 votes to end.

But those special rules would apply only to items that affect the federal budget. Republicans, for example, would need a simple Senate majority to end IRS penalties against people who don’t buy insurance but would still need 60 votes — requiring Democratic support — for other changes such as raising limits on older people’s premiums.

House Budget Committee Chairman Tom Price, R-Ga., says that will restrain Republicans’ ability to ram a “lock, stock and barrel” repeal through Congress.

GOP RISKS

One GOP danger: Congress and Trump might repeal Obama’s law, but while they’re laboring on a replacement, nervous insurance companies begin pulling out of markets and raising premiums. Insurers have been doing that under Obama, but now it would occur under a Republican government.

Another hazard: Congress’ work could spill into the 2018 campaign season, when the entire House and a third of the Senate face re-election. Republicans will grow increasingly timid about anything that might anger voters.

“We want to be the rescue party instead of the party that pushes millions of Americans who are hanging by the edge of their fingernails over the cliff,” says Sen. Lamar Alexander, R-Tenn., who chairs the Senate Health committee.

GOP PATHWAYS

Virtually all Republicans want to get rid of the health law’s mandates that individuals buy coverage or risk IRS fines, and that large employers insure workers.

They also want to erase taxes on higher-earning people and the health care sector. And they’d like to retain parts of the law guaranteeing coverage for people with pre-existing medical problems and keeping children under age 26 on family plans.

Unifying Republicans much beyond that is a work in progress.

Trump’s health care views have varied and lack detail. His campaign website touts tax deductions for health insurance premiums and permitting policies to be sold across state lines. He’d also revamp Medicaid, which subsidizes health coverage for low-income people, directing fixed amounts of money to states and letting them structure benefits.

House Speaker Paul Ryan, R-Wis., last summer unveiled an outline of the House GOP’s solution, though it lacked cost estimates and details. It would provide tax credits, impose taxes on the most generous employer-provided health care plans, revamp Medicaid and let Medicare beneficiaries pick private plans instead of today’s fee-for-service coverage.

Senate Finance Committee Chairman Orrin Hatch, R-Utah, has also advanced a framework relying heavily on tax credits.

REMAINING QUESTIONS

Thirty-one states — including Pence’s Indiana, where he is governor — plus the District of Columbia have expanded Medicaid coverage to 9 million additional people under Obama’s law. Curtailing that program will divide Republicans.

Taxing the value of some employer-provided health plans, aimed at curbing the growth of costs, is “a political land mine,” says GOP economist Douglas Holtz-Eakin. Republicans have long resisted tax increases.

Obama’s law mandates coverage for individuals because without that requirement many healthy people would forgo policies, driving up costs for everyone else and destabilizing insurance markets. Ryan has proposed shielding people from higher premiums if they’ve had “continuous coverage,” allowing higher rates for people who have not had policies, but Republicans have yet to decide how to keep insurance markets viable.